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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700914
Report Date: 03/20/2023
Date Signed: 03/20/2023 02:33:13 PM

Document Has Been Signed on 03/20/2023 02:33 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:POND BROOK HOME, INC.FACILITY NUMBER:
342700914
ADMINISTRATOR:CARPIO, ORLANDOFACILITY TYPE:
735
ADDRESS:8183 POND BROOK WAYTELEPHONE:
(916) 476-0882
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 4CENSUS: 3DATE:
03/20/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Administrator Orlando CarpioTIME COMPLETED:
02:45 PM
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Licensing Program Analysts (LPAs) Vincent Moleski and Jason Lund arrived unannounced for a case management visit regarding a facility action report from Alta California Regional Center (ACRC). LPAs Moleski and Lund met with administrator Orlando Carpio and explained the purpose of the visit.

Carpio said the staffing issue per the facility action report was related to documentation of staff schedules for one-on-one supervision.

LPAs Moleski and Lund reviewed resident files for R1 and R2. LPAs Moleski and Lund reviewed staffing documentation. LPAs Moleski and Lund tested the smoke detectors and observed they were working.

No deficiences were cited during this visit. LPAs Moleski and Lund conducted an exit interview and left a copy of this report with Carpio.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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